Le système de soins japonais : l’impossible et permanente réforme

Abstract

Cet article analyse les caractéristiques et les évolutions récentes d’un système de soins japonais confronté au triple défi du vieillissement de la population, de la nécessaire amélioration de la qualité des soins et de la maîtrise des coûts. L’article met l’accent sur la multiplicité des plans d’assurance maladie sur fond de couverture universelle, le déséquilibre de la relation médecinmalade et la coexistence, au Japon, de modalités privées et publiques de l’exercice de la médecine. Qu’il s’agisse de mettre en place une assurance spécifique pour les personnes âgées ou de rééquilibrer la relation avec le malade, les réformes sont mises en place de manière incrémentale (au sens de la théorie évolutionniste). Elles ont comme particularité de conforter les valeurs (l’équité), les institutions (l’administration et l’association des médecins japonais - AMJ), les procédures (la négociation continue), voire les outils (la nomenclature des actes) de la régulation du système de soins qui dominent depuis cinquante ans. De ce fait, les méthodes d’inspiration libérale, qui se développent dans les pays occidentaux, ne sauraient y trouver leur place.

This article analyses the main features of the Japanese health care system. It also analyses its recent changes facing the aging of the population, the need to improve quality of care and the necessity to contain cost. As far as the main characteristics are concerned, the accent is first put on the information asymmetry in the physicianpatient relationships. Then the so-called «clinics» are described as the symbol of the coexistence of private and public health service provision. Finally, the «fee schedule» is presented as one of the main regulation tools. As for the recent reforms, it is shown that they are implemented in an incremental way. That is to say that the recent changes maintain the core of the health care system. They comfort the main value (such as equity) and the main institutions involved in the regulation process (such as the central administration or the Japanese Medical Association). They also maintain the regulation process (i.e. the continuous negotiation). As examples of such reform strategies, the article deals with the creation of a new insurance for aged people (named long term care insurance), the changes in the health seeking behavior, the division of labor between health care providers and some preparative steps for possible unification of multiple insurance. It is for example shown that the collective management of the «fee schedule » leads to an actual incentive. It pushes forward some medical practices (such as the use of high technology screening) or slow down others (such as selling drugs). But it is also a symbol of the regulation process itself. In effect, as this list is regularly revised, it gives to all the partners the opportunity to meet each other, to build a rather broad consensus and, thus, to enhance the strength of the whole system. As a result it is shown that the market logic that many western countries try to implement, through managed care techniques, do not fit the Japanese system and must be seen as inefficient.